Life After (Weight) Loss

Kristin DiBiase struggled with obesity her entire life. In sixth grade, she weighed 212 pounds and went on her first diet and nutrition plan after she attended a weight management session at her local hospital in St. Louis. 

“By 11th grade, I leaned out a little because I had a growth spurt. At that point I was in size XL,” says DiBiase. 

When she went away to college in 1999, she gained a lot of weight. She was also diagnosed with depression during her first semester. “I was really having difficulty with my mental health,” she says. 

As she navigated her mental health, she continued to work on losing weight. During her junior year, she lost 40 pounds on the Atkins diet. But gaining and losing weight became a vicious cycle from that point forward. She went on to lose significant weight five times with different diets, including BistroMD, Weight Watchers, HCG diet, Nutrisystem, and Beach Body. “For me, it’s keeping the weight off that’s an issue,” says DiBiase. 

In 2012, she underwent bariatric surgery in hopes of keeping weight off. To prepare for surgery, she lost 40 pounds. After surgery, she lost an additional 40 pounds. “That is a sub-par result. Many people usually lose 100 pounds in the year after surgery,” she says. “I put everything into this and followed all protocols. For me, all the effort and resources I poured into this was disappointing.”

Turning to GLP-1s

On November 17, 2022, DiBiase started taking the GLP-1 medication Mounjaro off-label for the treatment of metabolic syndrome, a cluster of conditions, including obesity and high blood pressure, that increases the risk of heart disease, stroke, and diabetes. 

In 2008, during a depressive episode, DiBiase’s doctor suggested she undergo genetic testing, which revealed she had serotonin deficiency.

“The source of my health issues and obesity is rooted in neurotransmitters due to me having a serotonin issue, so I thought Mounjaro would be good,” she says. 

Since taking the medication, DiBiase has lost more than 41% of her body weight and is maintaining her body weight at around 145 pounds. 

“I got results immediately,” she says. “I constantly had food noise in the background around when can I eat again and preoccupation with food. Within a week of being on Mounjaro that was gone…I was in shock and almost didn’t have words to describe how I didn’t have to think about food anymore.” 

Losing Weight Comes With Complicated Feelings

Anything related to a person’s weight can come with complicated feelings: losing, gaining, or even staying the same, says Robyn Pashby, PhD, licensed clinical health psychologist and founder of DC Health Psychology. 

“First, because in the United States so much of a person’s self-worth has been linked to their appearance, which includes weight,” she says. However, another cause of complicated feelings after weight loss is that people may not realize that their weight loss journey is separate from their other life journeys like improvements in body image, their relationship with food, their mental health, or human relationships. “In other words, people may expect weight loss to ‘solve’ other struggles they have, but it rarely has that outcome in the long run,” says Pashby. 

When significant weight loss is intentional, she has witnessed clients feel a range of emotions from euphoria to desperation to disbelief. For example, for those who were restricted physically by their weight, losing weight can feel like a chance at freedom to move their bodies in ways that may have been hard before weight change. “For others, even losing extreme amounts of weight can be a disappointment if they are faced with continued body image disturbance or eating-related struggles after weight loss,” Pashby says. 

Ethan Lazarus, MD, past president of the Obesity Medicine Association and owner of Clinical Nutrition Center, says unexpected consequences of losing weight can range from feeling uncomfortable with newfound attention to mental health conditions from surgery or antiobesity medication.

“It is possible that people can become clinically depressed or even have suicidal thoughts,” he says. “Patients and their families should be counseled that if this were to happen, they should seek immediate treatment.” 

On a positive note, he adds that people who lose a lot of weight might have more energy, feel less pain, and are able to accomplish more. They may also have newfound motivation and confidence.

“People realize if they can lose weight they can do anything! They quit a bad job, or assertively request a long-earned promotion. They motivate those around themselves in a positive way, ‘If I can get healthier, you can too,’” says Lazarus. 

Less Weight Can Bring More Attention From Others

Pashby says many parts of the world still display weight bias and devalue people living with higher weight. 

“Therefore, some improvements in self-esteem may come from experiencing less weight-based discrimination,” she says. “Obviously, weight-based discrimination and bias are harmful and people shouldn’t have to fit into a societal standard to experience improvements in self-esteem.” 

While DiBiase has experienced more attention from men at her current weight, she says she doesn’t let it bother her. Plus, she is happily married. 

“When I was younger and on the scene with my friends, I would encounter a lot of men who you could tell had written me off cause they were not physically attracted to me cause I was a big girl. But I have a fun personality and mentally they were attracted to me so you could see the wheels turning in their minds; it was such a conundrum and they didn’t know what to do,” she says. 

Today, she says interactions are different because of her weight. However, instead of being mad or annoyed, she takes a practical approach. “I realized people are attracted to who they are attracted to. I’m not going to take on being pissed because there’s stuff I’m not attracted to—we all have our own preferences and it sucks if they don’t line up but that’s kind of pragmatically how I approach everything in life,” she says. 

Extreme Weight Loss May Influence Body Dysmorphia

After losing weight, a person’s views on body image and self-esteem often change. 

“Unfortunately, weight loss, particularly when it is significant, can lead to other struggles like body dysmorphic thoughts—those thoughts that get fixated on things ‘wrong’ with a person’s body,” says Pashby. 

Loose skin or other skin texture issues can be one source of negative thoughts after weight loss and can negatively affect body image and self-esteem, she adds. 

DiBiase relates. Because her weight fluctuated over the years, she had a closet full of clothes in different sizes. As she began to lose weight quickly while taking Mounjaro, it took her a while to process fitting into smaller sizes. 

“There was a lot of dissonance because I’m standing in an outfit that is visually too big in a mirror but I…look at myself and still feel like I’m way larger than I actually was,” she says. “It was really unsettling in a way.” 

Her feelings are common, says Lazarus. “For years they have been dissatisfied with their bodies, now they lost the weight, they are still just as dissatisfied,” says Lazarus. “Oftentimes we blamed the weight, but perhaps there are other things we should be looking at—therapy (individual or couples therapy, for example) can be very helpful in these situations.” 

Rachel Goldman, PhD, FTOS explains how much of this has to do with the way our brain has perceived and viewed us for all these years. "Unfortunately their brain can't adjust as fast as their body has and therefore, they may continue seeing the person in the larger body, although there is evidence that they have lost weight and their body has changed," says Goldman.

She continues: "I recommend that whenever people's automatic thoughts is that they are still at x weight, or in the larger body, to pause and examine the evidence. Remind themselves of all of the changes, including perhaps how their clothing size has changed, they are now able to climb the stairs without getting out of breath, etc. Sometimes trying on the larger size that they were and seeing how it is now too big on them is a wonderful reminder, but couple that with self-talk. The more they remind themselves of this, the easier it will become and it will help retrain their brain. Just as their brain learned, and got used to the image it saw before, it can relearn a new image—it just takes time so you need to be patient and consistent."

“That’s what I did to get myself out of this and to remind me that my brain is telling me things that aren’t real,” she says. 

How to Stay Mentally Well After Significant Weight Loss

As people lose significant weight while taking anti-obesity medications like GLP-1s, the following healthy habits can help them process the mental health effects.

• Visit your doctor regularly. During aggressive weight loss, Lazarus says to have weekly visits with a provider or registered dietitian. Once you are maintaining weight, monthly contact is often
  appropriate.
• Reduce stress by saying “no” to things you don’t want to do and engaging in self-care activities like meditation, exercise, or other things that bring joy.
• Get adequate sleep. “If there is not enough sleep, then the body is like a house of cards and everything will collapse,” says Lazarus.
• Address barriers to change, such as medications making it hard to lose weight, challenging interpersonal relationships, and access to appropriate foods and physical activities.
• Pay attention to self-talk. If your thoughts around your weight are emotion-driven themes like shame, self-criticism, or ‘not enough,’ Pashby says work to counter those negative thoughts with more fact-based thoughts. “Instead of getting stuck on ‘I should feel happy now that I lost weight,’ work towards something more like ‘I lost weight and while society tells me I should be happy, I know that I have more to my life and my happiness than my weight,’” she says.
• Remember your self-worth is not determined by the size of pants you wear, says Pashby.
• Embrace non-scale victories like not needing to ask for a seat belt extender on a plane ride or being able to chase your kids or your dog around your yard now that you are healthier. “For most people, losing weight is ultimately about health and these improvements can be easily minimized,” says Pashby. “But take note if you dropped a few medications or stopped needing a CPAP machine at night. These are huge victories that can help keep you feeling positive about your efforts.”
• Get professional help. If you struggle with countering negative thoughts or having a hard time coping with weight loss, find a therapist who has expertise in body image, weight, or eating. “[It] is normal to experience an influx of feelings that may be difficult to cope with,” says Pashby.